It is of major concern to me that peak bodies entrusted with the treatment, education and support of mothers with mental illnesses are following what they call a ‘simple and effective’ intervention to rid ‘problematic’ waking by their baby to facilitate the mother’s recovery. The intervention is Controlled Crying or Controlled Comforting.
The basis for this is that an ‘infant sleep problem’ is a strong indicator for maternal depression and ‘Infant sleep problems and postnatal depression are both associated with increased marital stress, family breakdown, child abuse, child behaviour problems and maternal anxiety. Postnatal depression can adversely affect a child’s cognitive development.’ (Royal Australian College of General Practitioners, 2014 )
These are seriously heavy consequences and certainly not something that can nor should be ignored, BUT the fact remains that by and large, very few babies genuinely suffer from true sleep problems and therefore it must be asked, if the baby itself is not behaving in a biologically unhealthy manner, should it be their normal, functioning behaviour that professionals look to intervene on, or should the interventions be focused directly on the person who is exhibiting the unhealthy, non functioning behaviour?
It is understandably a blurred line as the mother- baby dyad is unique and shouldn’t be treated in isolation but the current recommendations by the Royal Australian College of General Practitioners (RACGP) and the Raising Children Network as an arm of the Australian Government’s Department of Social Services to employ the Controlled Crying technique, in no way honour this dyad.
Yes, a mother’s mental health is essential to her ability to successfully and healthily mother her children but let’s not dive straight for the measure that provides a ‘simple and effective’ fix to her problem that has been in fact oversimplified and effectively silences a baby’s cry and therefore their ability to communicate their night time needs.
This problem is complex and delicate. What will be effective for both mother and child in one setting may not be for any other but I do believe there are processes that could be put in place in order to take a deeper more holistic approach to this very serious and critical issue.
The place to start should be the research into human infant’s biological sleep patterns and behaviours. No, not research into sleep problems and sleep training or interventions but a solid grounding in what is truly normal from a biological, physiological, psychological and anthropological stand point.
Starting with this baseline, scientific understanding will naturally lead those seeking information to learn more about the intricate link between infant sleep, breastfeeding, maternal sleep and sleep environments and situations.
From here, it is no stretch to see why the disconnect and misalignment of modern societal views and expectations of infant sleep has created incredibly difficult barriers and challenges for mothers to face while trying to mother her infant who understands and knows nothing of modern society and its expectations and being able to fit in to what is seen to be a ‘successful’ mother, wife, partner, friend, daughter, sister, employee, volunteer and community member.
The RACGP state, ‘ Infants with sleep problems are more likely to sleep in the parental bed, be nursed to sleep, take longer to fall asleep, and wake for often and for longer periods.’ I’d like this to be viewed in light of what normal infant sleep actually looks like in the 6-12 month age group of infancy. These are NOT sleep problems for the infant but DO pose sleep problems for their parents and in particular their mother particularly for parents who are unable, unwilling or unaware of what changes they need to make to their own sleep habits, lifestyle, environment and support network to enable them to meet these biologically normal sleep behaviours of their baby or toddler that are seen in every culture and society in the world but are only identified as problematic and linked so closely with the incidence of maternal depression in our Western societies.
The other side of this statement from RACGP is it is another nail in the coffin to very tired mothers everywhere to see once again, their child’s sleep behaviour being blamed on natural nurturing parenting behaviours.
It is normal and natural for an infant to sleep in a family bed. This is how the majority of culture’s in the world manage normal night waking of breastfed infant and toddlers. It is not and has never been the cause of a ‘sleep problem’ for a baby or child. It can and is done safely by most (not all) families.
It is normal for a human infant or toddler to be nursed to sleep. It is not a sleep problem. Our night time breastmilk is packed full of sleep inducing components that act to assist both mother and child to sleep more easily and remain more relaxed. Mother Nature is no idiot and this is by perfect design not error.
It is biologically normal for a human infant to wake and nurse frequently at night for the first year and beyond. It is not a sleep problem.
IF a baby is waking in an extreme fashion or staying awake for long periods on many occasions, then I urge all General Practitioners and other professionals on the front line who work with these vulnerable mothers to not ignore this key factor. Absolutely DO NOT take steps to extinguish this child’s cries and calls for help. There is highly likely an underlying issue exacerbating this child’s normal wakeful behaviour and they deserve to have this fully investigated. Reflux, allergies, food intolerances, tongue and lip ties, birth trauma and the residual discomfort from it are all possible issues that need to be looked into and ruled in or ruled out.
After all of the investigations have taken place, if nothing else is at play, please consider this child as a whole person. It is highly likely that a child waking in this extreme fashion is highly sensitive, extremely intense and requires a huge amount of parental nurturing to be able to regulate their body and mind throughout the day and also by night. It has been shown that some children are far more sensitive to parenting choices and techniques than others and I would argue that a baby exhibiting such high level needs could be safely considered a strong candidate to be one of the children who will be heavily effected by the way they are parented and as such, their parents and those acting to care for those parents, need to be mindful of what interventions are suitable not only for the mother but also her unique child.
This brings me to my next point, with so little focus on the well being of the baby in this advice, I would like to bring into question the Hippocratic Oath, ‘first, do no harm’. I have read the studies cited by RACGP and the Raising Children Network and there is a heavy bias toward Proof of Harm and in particular Proof of Harm in the short and medium term but I question whether this is enough. Proof of Harm is vastly different to Proof of No Harm and there is most certainly not any Proof of no harm. It also seems that RACGP has focused only on studies that support the method they wish to employ with no recognition of studies that indicate otherwise.
As the babies in these situations are not in fact the patients but are intricately linked to the problem and the solution, it is not enough to find that the improvement in maternal depression warrants the widespread use of these techniques that cannot be proven to be doing no harm to their babies. A solution that only considers the mother’s needs and sacrifices her baby’s need for night time parenting is frankly no solution at all.
I am no stranger to this situation. I have lived and survived an extremely wakeful baby, I have been referred to a Mother-Baby unit for sleep training by my GP, I have been diagnosed and recovered from Post Natal Depression, I have tried and failed to implement a modified Controlled Crying technique and my extraordinarily intense baby resisted all attempts to extinguish his cries. I have had to recover from Post Natal Depression while STILL mothering my extremely wakeful baby and therefore while still sleep deprived.
I take this topic extremely seriously. I do not doubt or question that many mothers who are given this advice and have implemented it to varying degrees of ‘success’ will largely attest that they NEEDED this intervention. I don’t question that they needed help but I do question that THIS intervention is what was needed.
I sincerely hope to see a shift in practice in the management of severe sleep deprivation, Post Natal Depression and the handling of infant sleep by the professionals mothers turn to for support and assistance at his extremely vulnerable time in her life.
I ask that RACGP, review their current guidelines and practice by seeking access to research and techniques that will give a fuller more human view of this issue for all people involved.
I am not an expert, so my thoughts may be largely dismissed but the true experts in this field are resources that RACGP should acknowledge. Here are a few to get the ball rolling:
- The Australian Association for Infant Mental Health has a position paper regarding Controlled Crying which can be accessed here.
- Dr Pamela Douglas who runs the Possums Clinic for mothers and babies in Brisbane, Australia is a wealth of knowledge on normal infant sleep and working with mothers during this weary season in their lives. The Possums Clinic also offers Professional Development opportunities for those working with vulnerable mothers.
- Tracy Cassells PHD of Evolutionary Parenting is a wealth of knowledge and can assist with identifying research from across this topic around the world.
- Professor James McKenna of Notre Dame University can offer an Anthropological understanding of infant and mother sleep particularly for breastfeeding mothers.
- Professor Helen Ball runs the UK Infant Sleep Information Source and is a wealth of information and will be in Australia in 2017 for professional development opportunities.
- Pinky McKay and Meg Nagle are both International Board Certified Lactation Consultants who offer alternative views on managing infant sleep with a particular focus on breastfeeding mothers.
If we as a society truly wish to see a change in the occurrence of Post Natal Depression and Anxiety in mothers, let’s work to create the environment and support they need to be able to mother their babies the way they need to be mothered while also being able to be mentally well and the best way to do this is to ensure all parties work together to find a solution that fits with all of the humans involved. Controlled Crying is hopefully soon to live in the deep, dark recesses of history. Our mothers and babies deserve better.
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